Healthcare Provider Details

I. General information

NPI: 1063680833
Provider Name (Legal Business Name): SURESIGHT AND ASSOCIATES L L C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2008
Last Update Date: 04/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 RIVERSTONE DR
CANTON GA
30114-5256
US

IV. Provider business mailing address

217 RIVERSTONE DR
CANTON GA
30114-5256
US

V. Phone/Fax

Practice location:
  • Phone: 770-345-5220
  • Fax: 770-479-5011
Mailing address:
  • Phone: 770-345-5220
  • Fax: 770-479-5011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License NumberGA1769
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT0001624
License Number StateGA

VIII. Authorized Official

Name: DR. DAVID JACKSON WAYLAND SR.
Title or Position: PRESIDENT
Credential: O.D.
Phone: 770-345-5220